Eosinophilic Esophagitis

Eosinophilic esophagitis is localized eosinophil-predominant inflammation of the esophagus; it is probably caused by food allergy and can cause reflux-like symptoms, dysphagia, and, in older patients, food impaction.

Eosinophilic esophagitis is an increasingly recognized disease that can begin at any time between infancy and young adulthood; it occasionally manifests in older adults. It is more common among males.

The cause is probably an immune response to dietary antigens in patients with genetic susceptibility. Esophageal inflammation causes irritant symptoms and ultimately can lead to esophageal narrowing and stricture.

Symptoms

Infants and children may present with food refusal, vomiting, and/or chest pain.

In adults, esophageal food impaction is sometimes the first manifestation.

Patients often also have manifestations of other atopic disorders (eg, asthma, eczema, allergic rhinitis).

Diagnosis

Endoscopy with biopsy

Sometimes a barium swallow

Often allergy testing

The diagnosis is often first considered when reflux symptoms fail to respond to acid-suppression therapy. It should also be considered in adults who present with esophageal food impaction or in adults who have noncardiac chest pain.

Diagnosis requires endoscopy with biopsy showing eosinophilic infiltration. Although visible abnormalities (eg, furrows, strictures, rings) may be apparent on endoscopy, appearance often is normal, so biopsies are essential. Because gastroesophageal reflux disease (GERD) can also cause eosinophilic infiltrates, patients who have mainly reflux symptoms should probably have endoscopy only after failure of a 2-mo trial of a proton pump inhibitor.

A barium swallow will show a feline or ribbed esophagus.

Testing for food allergies is often done to identify possible triggers (see Diagnosis); alternatives include skin testing, radioallergosorbent testing (RAST), or trial of an elimination diet.

Treatment

Topical corticosteroids

Dietary changes

Sometimes esophageal dilation

In adults, topical corticosteroids are usually given if there is a dominant stricture. Patients may use a multi-dose inhaler of fluticasoneSome Brand NamesCUTIVATEFLONASEClick for Drug Monograph (220 mcg) or budesonideSome Brand NamesPULMICORTRHINOCORTClick for Drug Monograph (180 mcg) 30 min before breakfast and 30 min before dinner; they puff the drug into their mouth without inhaling and then swallow it. BudesonideSome Brand NamesPULMICORTRHINOCORTClick for Drug Monograph (0.5 mg/2 mL mixed with a sugar substitute and swallowed 30 min before breakfast and 30 min before dinner) also can be mixed into a slurry and swallowed. They are given for 8 wk.

Dietary changes are also tried and are usually more effective in children than adults; food allergens identified by testing are eliminated from the diet or patients can follow a prespecified elimination diet (see Table 5: Allowable Foods in Elimination Diets*).

Patients who have significant strictures may need careful esophageal dilation using a balloon or esophageal dilator; multiple, careful, progressive dilations are done to help prevent esophageal tears or perforation.